A 79-year-old man was transferred from the medical floor to the psych ia trii; Hour because he was severely depressed following a myueardial infarction (MI). When iransíerred. his cardiac condition was stable: moderate heart failure. Like many elderly patients, he also suffered from multiple chronic illnesses. "Do Noi Resuscitate" (DNR) orders were placed in his chart. During the first month on the psychiatric floor, antidepressant medication was iried und slopped because oi' hypotension and mental confusion. An initial decision was also made not to try electroconvulsive therapy t ECTi because ol'ihe Ml. The patient had a history of depression that had been treated with remissions. In the second month of hospitalizaron, the palienl refused more frequently to eat and his liquid intake also decreased. The family was resistant io an intravenous (IV) or a feeding tube. The patient's condition continued to deteriorate. Both lhc patient's wife, who had recently been diagnosed as having cancer, and the patient's children wished no unusual measures taken, and they fell a feeding lube or IV constituted such measures. As the patient continued to refuse any nourishment or liquids, his physical condition became a matter of concern. Transfer back to medicine was considered. The unit clinical director was aware of the patient's status and requested a consult because he felt the DNR order and the withdrawal of comfort care (feeding) was inappropriate with this patient. The consult recommendation was to begin feeding and hydration and to consider ECT if the patient's status improved. Although the family objected, feeding and hydration were begun. The patient's status became so serious, however, that he was transferred to medicine for treatment of a worsening pnuemonia and for rehydration. He died 2 days later. There was no autopsy, at the family's request.
The sad story of (his patient and what was done tor and to him in his last days reminds us of what Hippocrates said in his Epidemics: "When a doctor can do no good, he must be kept from doing harm."
The trouble is that the ancient principle primum non naceré cannot be effectively enforced, not even in the goldfish bowl of modern consultative medicine, and this is because when physicians consult they hate to give venl to any truly flat disagreement they may have with their colleagues. In this case, judgments conflicled ihree ways, as between medicine, neurology, and psychiatry. The disagreement seems to have been about the perennial question, "Is death never to be welcomed?"
The issue was dramatized by the psychiatrist: he first wrote a DNR order and then reversed himself because the internist wanted to try artificial feeding and ECT.
Why did the psychiatrist write the DNR? Let us look at this 79-year-old patient's ills in loto. A history of diabetes mcllitus (type 11), pulmonary edema, congestive heart disease, cataracts, a benign left-brain tumor, repeated myocardial infarction, spleen and gallbladder removed, a leftbrain stroke, low blood pressure, syncope (îoss of respiration), arterial sclerosis (without occlusion). cognitive deficits, poor orientation, a history of depression ( now worsened ) . confused cum signs of hallucination, and lethargic reactions (partially due to medication). In addition, all of this was topped off with pneumonia, along with renal and liver failure.
Ancillary factors for the decision-makers were that the patient's wife was dying of cancer and she and the children were expressly opposed to heroic or extraordinary measures. Thus, (he daughter had refused to consent to IV and a nasal gavage (NG) tube in particular.
All of this helps us to understand (he psychiatrist's decision to let the patient go. At the same time it makes it hard to see why the internist wanted to resuscitate and, more than that, to use ECT in the hope that it would relieve the depression. Given the case data, we cannot suppose easily that the depression had no objective grounds, or that the family was welcoming too easily death's arrival.
The patient's 79th birthday came while hospitalized. Shortly after, his final collapse started. He told the staff he wanted to die. Psychiatry wanted Io return him to medicine because of his physical condition. A DNR was written. Neurology consult decided not to treat his seizures. The patient's internist siili wanted to try ECT, making it possible by what may be called iairly forced feeding, in spile of the high risks of heart failure. Two months after his birthday, lhc palient gol away altogether.
The question now arises, how can I be so positive that the psychiatrist was right to place a DNR order in the chart? I remember years ago writing an ethical analysis for the National Commission for the Protection of Human Subjects in medical research on the question of whether fetal research and the use of fetal tissue therapeutically can be morally justified, and at the end of it 1 wrote that "regulations by the public authority are unethical iG the reasons for them, the ethics they are rested upon, are not disclosed fully and frankly."1
In short, if we make value judgments, such as drawing quality of life conclusions in the care and treatment of patients, we owe it to others to explain honestly our basis for doing so,
My moral guideline is often called situation ethics, so cai/ed because it decides what is good or right according to what actual situations indicate as the most beneficial course to follow in the actual situation, rather than "applying" some abstract "principle" derived from a generalization about what is usually or typically the right thing to do in a class or category of similar cases. In short, as I view it, the internist was acting out some moralistic principle such as "life and its survival is the highest good," whereas he should have asked if biological survival for this patient in these circumstances was in the patient's best interest. To put it more succinctly, let the case decide what principles should be followed to realize the patient's greatest good - the most humane benefit.
This is a relative ethics, of course. It holds that life is good - arguably even the first -order good - but Jt is only one of several goods, and in some cases it is better to let life go. This means thai quality of life is the guideline, not any doctrinaire "sanctity of life." No absolute norms or values, no unexceptionable rules of practice, are to be embraced, except Io say that the patient's best interest according to the variables of the actual case is to be sought. In some situations death would be the enemy, in others a friend.
In the above case, the internist opposed the moral judgments of the patient himself, the patient's family, and his colleagues. It is hard to see how his desire to hydrate and then wreak convulsive shock on this particular palient with his array of illnesses could be explained on any grounds except a moralistic or absolutistic belief that survival is the right thing to try for regardless of the cost in terms of human well-being.
There are those who are absolutists about keeping patients alive in at least some minimal or biological sense. It is not clear that the internist falls into that class, and I would wager that if the position were put to him in so many words, he would reject it - or more probably, demur gently. It is also certainly true that the relativistic task of weighing up variant and competing values ean and does sometimes lead to different appraisals of cases and therefore different decisions. After the fact comment on this actual case, however, seems to offer little or no reason to applaud the internist for his judgment, or his colleagues for their fretful and supine roles.
We can be confident that any gathering of competent and experienced physicians in a clinicalpathologic conference would quickly reach a consensus along the same human lines that 1 have set forth, and that the pathologist's report when the discussion ended would confirm their judgments on very weighty empirical grounds.
1. The National Commission for [he Protection of Human Subjects of Bkimedk'al and Behavioral Research: Keial research: An tílhical appraisal, in Research tin the fetus. Department of Health. (:.ilui;aiion. anil Welfare Publication Nu. IUSI 76-128. 1975, pp 1-14.